CQRD Sleep Study Form "*" indicates required fields Please submit with a completed Referral Form to [email protected]. The following information MUST be completed in order to assess a patient’s eligibility for a direct at home sleep study as indicated by current regulatory guidelines. MBS will only fund a Home Sleep Study if STOP BANG ≥3 and ESS ≥8, otherwise a consultation with our Sleep Physician will be necessary before a MBS funded sleep study can be approved. MBS will only allow funding of a Home Sleep Study (item No.12250) once every twelve months.Patient DetailsName* Name Gender*MaleFemaleOtherPatient DOB* DD slash MM slash YYYY Contact No*Address*Referring DoctorName* Name Contact No*Address*Provider No*Signature*Date* DD slash MM slash YYYY Sleep Services* Specialist Consultations APAP Trial and/or Sleep Study Medical Conditions*STOP-BANG Questionnaire (MBS will only fund a Home Sleep Study if STOP BANG ≥3, otherwise a consultation with our Sleep Physician will be necessary before a MBS funded sleep study can be approved.)1. Snoring: (Do you snore loudly (Louder than talking or loud enough to be heard through closed doors)?)* Yes No 2. Tired: (Do you often feel tired, fatigued, or sleepy during daytime?)* Yes No 3. Observed: (Has anyone observed you stop breathing during your sleep?)* Yes No 4. blood Pressure: (Do you have or are you being treated for high blood pressure?)* Yes No 5. BMI: (Is your BMI more than 35kg/m2?)* Yes No 6. Age: (Are you 50 years or older?)* Yes No 7. Neck: (Is your neck circumference greater than 40cm?)* Yes No 8. Gender: (Are you male?)* Yes No The Epworth Sleepiness Scale (ESS) How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they would have affected you. Choose the most appropriate number for each situation. 1. Sitting and Reading.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing 2. Watching TV* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing 3. Sitting, inactive in a public place (eg. theatre or a meeting).* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing 4. As a passenger in a car for an hour without a break.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing 5. Lying down to rest in the afternoon when circumstances permit.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing 6. Sitting talking to someone.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing 7. Sitting quietly after a lunch without alcohol.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing 8. In a car, while stopped for a few minutes in traffic.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing Please ensure the following box is ticked and the referring doctor details are completed. The sleep study MUST be booked with this information.* The patient is aware of this referral. Date* DD slash MM slash YYYY
